019200724-7-8-2020-15-AS-HHUL-BRDSXT-20200710141629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200724
Report Date: 07/08/2020
Date Signed: 07/08/2020 11:54:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2020 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20200111211911

FACILITY NAME:	GRAND LAKE HOME		FACILITY NUMBER:	019200724
ADMINISTRATOR:	GUINTO, VERONICA B		FACILITY TYPE:	740
ADDRESS:	365 STATEN AVENUE		TELEPHONE:	(510) 836-7549
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	14	CENSUS: 12	DATE:	07/08/2020
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Theresa Benigno, Administrator		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

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Facility illegally evicted resident.

INVESTIGATION FINDINGS:

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On 7/8/2020 at 11:35am, Licensing Program Analyst (LPA) L. Francisco contacted facility to deliver complaint finding for the above allegation via tele-visit due to shelter in place directed by the Governor. LPA conducted tele-visit via zoom with Administrator, Theresa Benigno.

During the course of investigation, LPA obtained information, collected documents and interviewed staff. Based on information obtained, resident (R1) is being illegally evicted. Based on documents collected dated on 1/2/2020, R1 was issued a 30-day eviction notice because facility could no longer meet R1’s needs due to R1’s change in level of care. Based on record review, documentation revealed facility was aware of R1’s changed in health condition as an exception request was submitted and approved by CCL in October 2019. However on 7/8/2020, S1 stated that facility rescinded the eviction and R1 is no longer being evicted.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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